Authorization for Release of Protected Health Information

Authorization for Release of Protected Health Information

Please complete the form below to authorize Access TLC Home Health Care to release protected health information as outlined. Ensure all required fields are filled out accurately, including signatures and dates, to properly process your authorization.

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This field is for validation purposes and should be left unchanged.

For the purpose of coordinating my healthcare and medical care needs, the above-named individual hereby authorizes Access TLC Home Health Care to obtain any and all protected health information through electronic mail, fax, paper copies, digital/electronic records, and Health Information Exchange (HIE) from any and all of the following health and medical service providers:

  • California Department of Social Services including but not limited to, In Home Support Services, and any and all Medi-Cal offices.
  • California Department of Developmental Services including but not limited to Regional Centers.
  • Any and all Hospitals, Physician/Medical Offices, Facilities, Mental Health Service Providers, and any other Medical Service Provider not already listed above.

THIS AUTHORIZATION DOES NOT EXPIRE AND IS VALID
AND ENFORCEABLE UNLESS REVOKED IN WRITING.

I understand that by signing this authorization:

  • I authorize the use or disclosure of my individually identifiable personal health information as described above for the purpose listed.
  • I understand that this authorization does not expire and that I have the right to withdraw permission for the release of my information. If I sign this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed.
  • I have the right to receive a copy of this authorization.
  • I am signing this authorization voluntarily and I understand that this form is required in order to obtain my medical records necessary to be evaluated for eligibility criteria for Medi-Cal Programs.
  • I further understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose the medical information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law.
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Our Mission

Access TLC is to provide unparalleled quality of service that allows patients to have a better quality of life. Our caregivers have decades of combined experience in hospice and home healthcare, and we utilize state-of-the-art equipment to guarantee the utmost comfort and peace of mind as our patients navigate the home healthcare process.

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CARE SERVICES

Our home health care service is for patients who need care from highly trained, highly skilled providers. Our goal is to help patients to function independently at home, to increase their comfort and to improve their overall health. Patients are eligible if they are homebound and under the care of a physician who certifies that they need one of more of the following:

  • Intermittent Skilled Nursing Care
  • Physical Therapy Services
  • Speech/Language/Occupational/Therapy
  • Pathology Service

Our home health care services include but are not limited to:

  • Nursing Assessment
  • Medication Management
  • Home Health Aide Services
  • Bathing & Dressing
  • Rehabilitation Therapy
  • Home Safety Evaluation
  • Medical Social Services
  • Treatments & Injections
  • Dressing Changes & Wound Care
  • Post-Op Care
  • Incontinence Care
  • Restorative Care
  • Patient & Family Education

Home Hospice is a program of care designed to relieve and manage symptoms related to a terminal illness and to help the patient and family with emotional and spiritual support during the end of life. Hospice provides extra care and comfort in the patient’s home, hospital, long-term care facility or wherever the patient resides.
Hospice offers:

  • Palliative & Support Care
  • Bereavement Grief Counseling

The services offered include:

  • Physician Services
  • Skilled Nursing Services
  • Physical/Speech Therapy
  • Medical Supplies & Equipment
  • Dietary Counseling
  • Bereavement Counseling

Seniors step out of the house less often as they get older. Many of them rely on visitors to socialize and seek companionship. Companionship is correlated to their health and overall well being. We provide caring, competent and dedicated professionals to care for those who need it. We work with patients and their families to design a program of care, and hourly shifts based on their needs.

Private pay services include:

  • Bathing/Showering Assistance
  • Continence Care/Toileting Assistance
  • Personal Hygiene Care/Skin
  • Care/Grooming
  • Companion Services for Recreational
  • Activities
  • Dressing Assistance/Clothing Selection
  • Errand Running/Groceries/Shopping
  • Eating Assistance/Meal Preparation
  • Transferring/Repositioning Assistance
  • Wake Up/Tuck-In Services
  • Linen Changes/Laundry Services
  • Washing/Drying Dishes
  • Appointment Reminders
  • Vacuuming/Dusting
  • Personal Care Services

All Transport Care provides professional, comfortable and dependable non-emergency transportation services. We are a reliable service with over 20 years of experience providing Continuum of Care Services.

We are proud of our excellent relationships we maintain in the community with Physicians, Medical Groups, Hospitals, as well as the major Health Plans. Our services are designed to fit common and special-needs situations which include bariatric, inaccessible areas, staircases, and long distance transports.

We help clients who are bed-bound, or have limited body flexibility and need to transport in a stable and lay-down position throughout the entire trip. Perfect for individuals who are wheelchair bound and unable to transfer safely to a passenger vehicle.

The transport services we offer include but are not limited to:

  • Stretcher/Gurney transport
  • Wheelchair lift service
  • Specialty transit
  • Medical appointments
  • Bariatric transport
  • Dialysis treatments
  • Discharge to home or facility
  • Dental appointments
  • Transferring to the facility
CALL 800-TLC-9887